Post Op Path - looking for information for next appointment

First, a huge thank you to all of you who have shared your experiences on your journey – extremely helpful and more importantly, an excellent resource for those diagnosed and living with PCa.

I had the surgery a few months ago (signature to follow) and during my follow up – the RALP surgeon ordered a Decipher test for me. We discussed the probability of doing ART (up to me) and I’m meeting with the RO this Friday. Decipher came back with a 0.7 which he told me that higher risk for reoccurrence – plus my SVI / ECE.

But, based on my post op pathology report, my Gleason was low but with left side SVI and ECE.

I seem to be a mixed bag based on the path report below!

Recently was looking through some posts and was pointed in the Cleveland Clinic Risk Calculator with Adjuvant Radiotherapy https:// http://riskcalc.org:3838/prostatecancerpredictingpostradicalprostatectomy/

And I’m having a little difficulty with the Capsular Invasion Type section (None, Inv.Capsular, Focal, Extensive) – not really finding reference to it on the path report or I’m missing it. Perhaps it is referenced in the margins section below (Anterior, Lateral, Posterior and overall)

There is a reference to Focal in the Gleason score when the tertiary is considered

Reason for asking – the Capsular Invasion Type section selection greatly changes the probability outcomes

Path report

Final Gleason, Primary 3, Secondary 3, Tertiary 4 (10%) Says Gleason Total 6, Focal 7 ((biopsy was 3+4; 2 cores 7, 3 cores 6 of 12 taken – Esptein’s JH analysis of biopsy agreed))

SVI + (left side), ECE +, Margins -, Bladder Neck -, Apical -, Anterior, Lateral, Posterior –
Lymph – (0 of 12)
Tumor Quantitation = 40 – 50%
Path staging pT3b

3 month post op UPSA <.006
Next one is scheduled for Jan 2020

Perhaps others have encountered the Capsular Invasion question and was able to interpret based on the above or point in better direction with finding.

Thanks

Post Edited (itllbeok1) : 11/17/2019 5:11:27 PM (GMT-7)

Somebody said...

OK, so I'll admit that I'm not one of the guys here who believe that ADT should be done automatically based on things like ECE or SVI. For me, I'd be watching and waiting for something to present itself. Others believe in being more pro-active. You'll hear all of those perspectives. How are you doing on side effects?

Side effects - I'm down to 1 pad a day - but wear it more to be cautionary when I'm at work. I don't mind using them. Urine flow has been much better and less frequent. I'm walking a lot (thanks to your suggestions Halbert) and just started to do some light weight bearing training.

This follow up appointment is only for Adjunctive Radiation consult - surgeon has not, to date, discussed hormones yet, could be because of the Path Report. I'll take the report with me and a tablet to the RO appointment to go over the Cleveland Clinic outputs.

Massive difference with the percentages when looking at the Capsular Invasion Type but not finding it anywhere on the report unless I'm missing it!

Thanks Andrew - definitely a mixed bag report
I was seriously thinking of asking for the post op slides to be sent to Epstein and may do so

I had met with the same RO in my discovery phase back in April - the machine they use are in his outpatient site. We'll see what he has to say later this week!

I did exactly the same thing as you are doing with a worse Gleason opinion from Epstein. I chose ART due to my G9 classification. I would have waited if it had not been so high and closely monitored PSA before the next step.

My reading of the CC capsular invasion type is that focal is a penetration in one area vs multiple locations if you can determine that. Not exactly sure what that means when you are pT3b though.

My RO did not recommend ADT with ART for undetectable PSA based on various studies showing no benefit. I think you may find that your Uro and RO may not be too helpful with this dilemma if like mine. The first thing they mentioned was adjuvant radiation then said I could wait if I wanted and see what happens with PSA, arghh! My Uro later said it would make sense to wait until continence and ED resolved before moving to radiation. Luckily, I did not have a continence issue so I moved ahead with just the ED issue not resolved at zapping time.

Sounds like you need some more opinions on your pathology and treatment options. A good RO will be helpful but keep in mind that they do radiation so that is what they tend to recommend. The Cleveland Clinic calculator is encouraging for ART so that helps but radiation is not side effect free so that has to be considered, especially if there are still post surgery recovery issues.

I would not wait for it to show up on PSA reading, I would go for Radiation now. Yeah, there is lot of discussion,you just don’t want to be on the wrong side of the statistic. At least you will be satisfied you did everything. This PC is a beast you have to hit it hard as it’s lying low.

Maybe call the pathologist and they can explain their report, focal 7 is odd way of saying something.

I thought ECE has about the same prognosis as a positive margin. But...

SVI+ is not a “wait ‘n see” finding.

That where the pt3 is coming from.

Good luck with your appointment.

You are certainly proactive in your treatment - that’s great to see. I sense that you are leaning (maybe) towards ART. If you are healed from surgery, and make the determination that you will follow up with RT, then waiting doesn’t make sense.
In your situation I’m not sure I would initiate RT treatment until a clear upward PSA trend presents. RT is not always without significant consequences.

Following my RP my urinary flow and frequency greatly improved. Following ART my flow was still good, but I went back to having to pee 4X per night during sleep. My RO's explanation for this was a hardening of my bladder wall by the RT.

As far as ADT for ART/SRT, here is a link to a recent ASCO review article. Their conclusion was for recommending the addition of ADT to SRT only for PSA above 0.5.

https://ascopubs.org/doi/full/10.1200/edbk_200319

Good luck with whatever choice you make!